A Simple Miracle: Treatment for Mysterious Foot Pain
Under the old ICD-9 diagnosis codes, there was actually a diagnosis for "adventures in medical mismanagement" to describe patients who had been run down the rabbit hole of poor case management and care. I encountered one of those patients in my office today.
Electrotherapy Gives Hope for Patients With Spinal Cord Injury
There has been little optimism for recovery from a spinal cord injury because the central nervous system does not repair itself well. The severity of the injury depends on the affected area.
2018 Gallup-Palmer Report: Key Findings
The fourth annual Gallup – Palmer College report is out; here are some of the key findings excerpted directly from the executive summary regarding Americans' experiences with chiropractic care relative to the management of neck and back pain:
VA Chiropractic Reduces Veterans' Use of Opioids?
Utilization of pain medication – particularly opioids – has been massively high in among veterans for decades, but Veterans Administration guidelines that recommend nonpharmacological first-line treatment options create a greater opportunity than ever for VA chiropractors to make a dent in the opioid and overall pain-management crisis.
The Top 5 Strategies to Manage Your Reputation Online
You don't need an acupuncture website anymore! Okay, maybe that statement is a little over the top. But it's not that far from the truth. A recent study on Google searches revealed that 34 percent of all searches resulted in no clicks at all.
Knocking Down the Doors: Big Media Success for F4CP
Three articles authored by a DC or a chiropractic organization and promoting the value of chiropractic care – par for the course if you're Dynamic Chiropractic, but if you're Forbes, BOSS Magazine and Becker's Spine Review, three media outlets tailored toward high-level executives and decision-makers, we're talking about an entirely different story.
A New President for AOMA: A Conversation With Mary Faria
Dr. Faria was formerly a health care executive for over 30 years, the last 17 of those years as vice president and chief operating officer of Seton Southwest Hospital in Austin. She chairs the board of Austin Mayor's Health and Fitness Council.
VA Choice Claims Denied? Here's How You Can Get Paid
The VA Choice Program (PC3 as well) indeed pays for chiropractic care including manipulation (CMT 98940-98943) and some physical medicine services.
Cynicism and Burnout: It Can Happen to You
Trying to achieve fulfillment as a doctor in today's health care environment is a "rigged game" and physicians are programmed to burn out. At least this is the opinion of Dike Drummond, MD, in his thehappymd.com blog.
News in Brief
A Comprehensive Model of Spine Care; Dr. Christine Goertz Appointed Vice Chair of PCORI Board of Governors.
Malpractice Insurance: Understanding the Cover Letter
Purchasing medical liability insurance is quick, easy and not terribly expensive. The benefits are clearly listed on a certificate—but do you really know what you are getting with that peace of mind?
Bad for the Back! Exercises That Can Prevent Healing
The questions "Who gets well? Who doesn't? Why?" prompted the following observations based on my close to 40 years of chiropractic practice.
A Guide to CBD Dosing: The Correlation Between Dose & Potency
There is an abundance of information available about the daily use of whole plant hemp CBD oil to help maintain and support a healthy lifestyle, however there remains a lack of sound guidance on CBD oil dosing.
Goodbye, Year of the Dog: Two-Thousand-Eighteen Comes to a Close
As Year of the Dog (2018) comes to a close we can look back and see the progress this profession has made. For example, the International Classification of Diseases (ICD) added traditional medicine codes, which were released in June.
The Raw Food Debate: Practitioners Discuss Nutrition & TCM
Licensed acupuncturist and fellow blogger Elissa Gonda joins this month's column for a conversation about raw food diets. She brings her perspective on the healing potential of a raw primal diet.
The Truth About Malpractice Claims Against DCs (Pt. 1)
Over the past 20 years of active practice, I have seen a number of scary case scenarios regarding signs, symptoms and patient presentations in my office. These presentations scream, This patient is going through an event or This patient does not need chiropractic care, they need emergency care.
Dietary Supplements That Help Restless Leg Syndrome
It is estimated that 7-10 percent (possibly up to 15 percent) of the U.S. population has restless leg syndrome. It is a bit more common in women than men.
Year in Review: DC's Best of the Best for 2018
As 2018 winds down, let's highlight the most popular articles in Dynamic Chiropractic by month (December – this issue – excluded, of course).
A Soy Isoflavone That Packs a Punch: Genistein
Soybeans contains unique substances called isoflavones, most notably genistein and daidzein, which have been shown to block the buildup the dangerous type of testosterone in the prostate gland linked to prostate enlargement and prostate cancer.
Reaching for Our Roots: Healing Digestion With a Simple Traditional Therapy
Are you ignoring a powerful tool in your doctor's bag? Many acupuncturists realize that Spleen Qi deficiency has reached epidemic proportions in the U.S. Yet, we don't prioritize educating our patients about the importance of warm, cooked foods.
Map It: Understanding the Customer's Journey
One of the biggest marketing mistakes most practice owners or administrators make is not putting themselves in their prospective or current patients' shoes. How do they think and feel about you and your practice? What makes them take action?
ACA Champions H.R. 7157; ICA Voices Major Concerns
While the American Chiropractic Association recently penned an open letter – signed by not only the ACA, but also the Congress of Chiropractic State Associations, Association of Chiropractic Colleges, Clinical Compass and a number of state associations.
Exercise Therapy Following Motor Vehicle Trauma (Pt. 2)
In cases of cervical spine trauma, particularly trauma related to a motor vehicle accident, my plan is to teach the patient one exercise per session and build a progression. This is an effective approach I call an "activation circuit."
Reality Check: Do We Need to Try Harder?
While waiting for a flight to a recent chiropractic event, I overheard the ticket agent at the gate next to mine on his cellphone. His side of the conversation went something like this: "Where are you now? How long before you think you can be at the gate? OK, that will work, see you soon."
When Computers Cause UCS: Adjusting Strategy
With the widespread use of mobile devices such as smartphones and tablets, the incidence of "text neck" has reached almost epidemic proportions. But there is another challenge to the spinal health and well-being of our technology-driven society.
Acupuncture in Hospital Systems: Transitioning From Tolerated to Celebrated
I've had the pleasure of working with Susan Luria, Director of University Hospitals Health Systems Connor Integrative Health Network (CIHN) for the past year on the Integrative Health Policy Consortium (IHPC) Board of Directors and Federal Policy Committee.
July, 2015, Vol. 15, Issue 07
We Have Much to Learn from Current Fascia Research
By Leon Chaitow, ND, DO
Fascia is fashionable. Over the past few years, you may have noticed the increase in conferences, congresses, symposia, workshops, online courses, books and articles that contain the word fascia in their title.Fascia was, for many years, seen as a sort of second-class tissue, a form of supportive wrapping, a nuisance during dissection, where it obscured the views of pretty muscles and joints. Fascia's increased visibility, due largely to the series of International Fascia Research Congresses, has attracted publication of a huge number of serious basic science research papers, as well as an avalanche of clinically related, fascia-related articles. These articles range from a focus on the fascial influences of foam-rolling, kinesiotaping, connective tissue massage, muscle-energy and other stretching techniques, myofascial release, a variety of exercise models (with plyometrics taking the lead), as well as a range of new trademarked approaches, led by the Italian export Fascial Manipulation.
One of the surprising features resulting from current fascia research (and there is an awful lot of it) is how little our increased understanding of fascia's functions has changed what manual therapists actually do – or need to do.
Rather, I believe, greater fascial awareness and understanding helps most therapists to do what they already do, more effectively, rather than having to relearn their skills. I have outlined a few examples of this here.
Before looking at examples of how emerging fascial knowledge refines, but doesn't necessarily change, what we do – it's important to establish a basic fact: It is impossible to treat fascia directly (short of actual surgery). In fact, all treatment approaches that target the soft tissues of the body, the muscles, ligaments, tendons and of course the joint-related tissues must involve fascial structures. The key message here is that it is not possible to "treat," - for example, a muscle (in any way whatever), without fascia being a feature of the process.
This elegantly phrased quote, from a research article by Weppler & Magnusson (2010), summarizes this point: "Skeletal muscles comprise contractile tissue intricately woven together by fibrous connective tissue that gradually blends into tendons...made of fibrous connective tissue [that] attach the muscle to bone. Although contractile tissue and tendons are sometimes evaluated separately for research purposes, they cannot be separated during routine clinical testing and stretching procedures, nor during functional activity," nor, of course, during manual treatment.
Five Clinically Relevant Examples
Note: This is not a definitive list. I have selected some key examples, there are many others!
Load transfer via fascia. Load-transfer research demonstrates how force is transmitted from one part of the body to another via fascial connections (described by some as "chains" and others or "trains"). For example, Carvalhais and colleagues (2013) demonstrated how contraction of latissimus dorsi – during adduction of the shoulder - produces external rotation of the contralateral hip via the superficial layer of the thoracolumbar fascia; while Stecco et al., (2013) showed how gluteus maximus contractions directly influence the knee via the iliotibial band. Potentially, therefore left-knee dysfunction could involve right latissimus dorsi behavior. Awareness of such links would not necessarily alter your treatment methods, but might well cause you to look at a wider set of possibilities when seeking causes of knee pain.
Fascia's sliding and gliding fascial functions. The different layers of the body - for example, between muscles or separating dense fascial structures from muscle or from other fascial layers – contain viscous loose connective tissues that allow a gliding, sliding function, protecting sensitive neural structures, as well as facilitating pain-free, efficient movement and force transmission, as described above. Gliding function may be lost because of trauma, inflammation or aging, resulting in fibrosis, thickening, densification. (Pavan et al 2014). Knowledge of the sliding functions of fascial tissues might not change what you do at all, but may help to explain why attention, lightly applied, as in myofascial release, can offer such dramatic benefits.
Mechanotransduction or changing cell behavior: for example, reducing inflammation and speeding healing of damaged tissues. Mechanotransduction describes the many ways in which cells respond to different degrees of load, such as pressure, tension, stretch, friction, etc. Research using important fascial cells (fibroblasts) that are largely responsible for the early stages of healing traumatized tissues, has shown that when these cells have been distressed by many hours of rapid movement, so that they start producing inflammatory chemicals, a brief period (a minute to 90 seconds) during which the cells are "treated" with the equivalent of myofascial release (MFR) or positional release (strain/counterstrain or SCS) – normalizes them. (Standley & Meltzer 2008.)
When MFR methods are applied to fibroblast cells in damaged tissues, a speeding up of the repair process is observed. (Hicks et al 2012). More recently, Cao et al (2015) conducted research on bioengineered tendons that had been artificially injured, to see how different degrees of light load (as in MFR) would effect the healing process. They tested a variety of degrees and durations of light stretching and identified that particular variations. For example, three minutes of stretch using around 6% of stretch, was effective in speeding up repair, while 12% for five minutes slowed it down. These percentages represent the degree of increased length of the tendon induced by stretching.
This remarkable research does not change the way gentle MFR or SCS are applied in manual therapy treatments of injured, painful, irritated, inflamed tissues – but helps explain why stronger degrees of stretch may not be as effective as light load.
Fluid dynamics and pain reduction. Manual methods that use isometric contraction – such as Muscle Energy Techniques (MET) – have the effect of improving fluid movement, particularly involving fascial fibroblast cells. Changes in the hydrostatic pressure in fascial tissues leads to improved drainage, reducing inflammatory chemicals (Langevin et al 2005, Fryer & Fossum 2009).
This is another example of fascial research indicating why (and how) mild stretching methods, particularly those involving isometric contractions, are effective in pain management. The information doesn't change the treatment methods, but it does clarify our understanding of what's happening.
Eccentric MET stretch and fibrosis, post-surgery. Remarkable clinical work in India, by orthopedic surgeons working in rehabilitation of individuals who have had recent hip or knee replacement surgery, or surgical repair of fractures, has demonstrated the value of slowly applied isotonic-eccentric stretching in such cases, thus reducing fibrosis and speeding recovery compared with traditional passive stretching methods. These MET variations have been successfully used for many years, by osteopaths and manual therapists in treatment of musculoskeletal dysfunction and have now been scientifically validated. Although this clinical research adds a wider range of application for MET, it does not change the way many of us already use this valuable method (Parmar, et al 2011).
The Bottom Line
Current fascia research is informing us, refining rather than revolutionizing what we do. Understanding the mechanisms of what we do in practice can help in the choice of what methods are best for particular clinical settings - how to best apply the multiple tools that manual therapists have for the optimal benefit of patients.
You may have noticed that the examples I have given in this article largely focused on biomechanical (and fluid related) effects of manual treatment. Apart from these there are, of course, important neurophysiological effects but that's a whole other story for another time.
Click here for more information about Leon Chaitow, ND, DO.
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